Expert Review of Cardiovascular Therapy

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Pathophysiology and mechanisms of Acute

Coronary Syndromes: atherothrombosis, immune-
inflammation, and beyond

Giovanni Cimmino, Luigi Di Serafino & Plinio Cirillo

To cite this article: Giovanni Cimmino, Luigi Di Serafino & Plinio Cirillo (2022)
Pathophysiology and mechanisms of Acute Coronary Syndromes: atherothrombosis, immune-
inflammation, and beyond, Expert Review of Cardiovascular Therapy, 20:5, 351-362, DOI:
10.1080/14779072.2022.2074836

To link to this article: https://doi.org/10.1080/14779072.2022.2074836

Published online: 17 May 2022.

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EXPERT REVIEW OF CARDIOVASCULAR THERAPY
2022, VOL. 20, NO. 5, 351–362
https://doi.org/10.1080/14779072.2022.2074836

REVIEW

Pathophysiology and mechanisms of Acute Coronary Syndromes:

atherothrombosis, immune-inflammation, and beyond
Giovanni Cimminoa, Luigi Di Serafinob and Plinio Cirillo b

a
Department of Translational Medical Sciences, Section of Cardiology, University of Campania “Luigi Vanvitelli”, Naples, Italy; bDepartment of
Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy

ABSTRACT ARTICLE HISTORY

Introduction: The pathophysiology of atherosclerosis and its acute complications, such as the Acute Received 26 January 2022
Coronary Syndromes (ACS), is continuously under investigation. Immunity and inflammation seem to Accepted 4 May 2022
play a pivotal role in promoting formation and grow of atherosclerotic plaques. At the same time, plaque KEYWORDS
rupture followed by both platelets’ activation and coagulation cascade induction lead to intracoronary Atherosclerosis; Immune-
thrombus formation. Although these phenomena might be considered responsible of about 90% of ACS, in inflammation; MINOCA;
up to 5–10% of acute syndromes, a non-obstructive coronary artery disease (MINOCA) might be documen­ thrombosis
ted. This paper gives an overview on atherothrombosis and immuno-inflammation processes involved in
ACS pathophysiology, also emphasizing the pathological mechanisms potentially involved in MINOCA.
Areas covered: The relationship between immuno-inflammation and atherothrombosis is continuously
updated by recent findings. At the same time, pathophysiology of MINOCA still remains a partially
unexplored field, stimulating the research of potential links between these two aspects of ACS
pathophysiology.
Expert opinion: Pathophysiology of ACS has been extensively investigated; however, several gray areas
still remain. MINOCA represents one of these areas. At the same time, many aspects of immune-
inflammation processes are still unknown. Thus, research should be continued to shed a brighter light on
both these sides of “ACS” moon.

1. Introduction
Atherosclerosis represents the anatomo-pathological substrate
of Acute Coronary Syndromes (ACS) in more than 90% of cases
[1–3]. A large mass of studies have extensively investigated
how atherosclerosis begins and develops, and it is now recog­
nized that it might be considered a chronic immune-
inflammatory disease starting with deposition of lipids within
the intima of the vessels, involving blood cells belonging to
both innate and acquired immune system [1], and then, it
progresses with cellular and inflammatory response against
undefined antigens [4] finally causing plaque grow and for­
mation of a “stable” stenosis of arterial vessels. When plaque
becomes “unstable” as consequence of rupture, erosion, and/
or ulceration, activation of both coagulation cascade and pla­
telets causes intravascular thrombus formation and thrombo­
tic vessel occlusion. Therefore, the term atherothrombosis has
been proposed to better describe this process [5]. Clinical
manifestations of stable coronary atherosclerotic stenosis are
represented by effort angina or dyspnea associated with tran­
sient ECG signs, which occur when coronary reserve is signifi­
cantly reduced. On the contrary, rest angina and persistent
ECG modifications are signs of abrupt coronary blood flow
reduction due to plaque rupture and coronary thrombosis
[6]. As reported in Table 1, in about 10% of patients with
ACS, acute myocardial ischemia is not associated with
atherothrombosis because coronary angiography does not
reveal a culprit lesion. In these cases, a functional alteration
of coronary circulation involving either large epicardial coron­
ary arteries or the coronary microcirculation has been indi­
cated as responsible of the acute event [6]. Specifically,
macrovascular and microvascular spasms have been postu­
lated to be responsible of ischemia with the clinical manifesta­
tion of non-obstructive coronary artery diseases (CADs)
(MINOCA) [6,7].
Although mechanisms of atherothrombosis have been
extensively investigated and the biological pathways under­
lying the conversion from asymptomatic or stable chronic
angina to ACS have been widely studied, the complex patho­
physiological puzzle of this disease has still some gray areas.
At the same time, the basic mechanisms by which cardiovas­
cular risk factors might induce coronary reserve reduction
(because of non-angiographically significant atherosclerotic
stenosis or functional alteration of coronary circulation)
remain to be better elucidated.
In this article, we first provide an overview on the main
mechanisms involved in pathophysiology of ACS, and then,
we discuss the hypothetical pathological mechanisms to
explain how functional alterations of the coronary circulation
(at both macrovascular and microvascular level) might be
responsible of the clinical manifestations of ACS.

CONTACT Plinio Cirillo pcirillo@unina.it Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy, Via S. Pansini 5,
Bilding 2- Naples, Italy
© 2022 Informa UK Limited, trading as Taylor & Francis Group
352 G. CIMMINO ET AL.
Article highlights
● Atherothrombosis plays a key role in the majority of ACS: plaque
rupture exposes intraplaque thrombogenic components to the flow­
ing blood, such as TF, leading to coagulation cascade activation with
final intravascular thrombus formation.
● The immuno-inflammatory modulation of atherosclerosis with still
unknown “intraplaque antigen” activation of the immunocompetent
cells is now well documented and accepted.
● Platelet aggregation cannot be considered only the final event of
coagulation cascade. Activation of platelets occurs via a complex
process that involves modulation of the proteome, transcriptome,
and miRNOme.
● A not negligible percentage of ACS is related to non-obstructive
CADs (MINOCA) where a macrovascular or microvascular disorder
may occur.
● Several gray areas remain to be explored: 1) the identification of
possible antigens responsible of activation of immuno-inflammation
cells; 2) the definition of platelet role beyond thrombosis; and 3) the
improvement of our knowledge on the pathophysiology of MINOCA
to provide the patients with the best tailored therapy.
2. Atherothrombosis: a history that starts with
endothelial dysfunction, continues with lipids
deposition, and ends with thrombus formation
2.1. Pathophysiology of plaque grow
Endothelial dysfunction has been recognized as the initial step
of atherosclerosis [8]. In physiological condition, endothelium
exerts several anti-atherothrombotic functions because it has
anti-inflammatory and anti-mitogenic properties, contractile
activities, and regulatory effects of the hemostasis process
[9]. The conventional risk factors such as hypercholesterole­
mia, hypertension, diabetes mellitus, and smoke are the main
determinants of endothelial dysfunction [10,11]. Once
endothelial dysfunction occurs, atherosclerosis continues
with lipid deposition within the arterial wall. This phenom­
enon seems to be the consequence of an unbalance between
the “influx” of cholesterol (mainly related to low-density lipo­
proteins) and “efflux” of cholesterol (mainly high-density lipo­
protein), thus leading to the primary step of atherosclerotic
Table 1. Main causes of Acute Coronary Syndromes according to pathological substrate.
Anatomical localization
Plaque-related disease Epicardial compartment Atherothrombosis
Epicardial and microvascular Plaque rupture/erosion and distal
compartment embolization
Coronary microvascular Epicardial compartment Epicardial vasospasm
dysfunction
Microvascular compartment Microvascular spasm and/or
structural remodeling
CRF: Coronary Flow Reserve; FFR: Fractional Flow Reserve; IMR: Index of Microcirculatory Resistance; IVUS: Intravascular Ultrasound; OCT: Optical Coherence
Tomography
lesion formation [12]. At this stage, retention and modification
of LDL particles (mainly the oxidized forms, oxLDL) and sub­
sequent accumulation in the intima are the initial trigger of
the endothelial dysfunction [13]. High levels of LDL cholesterol
seem to be the major determinant for this effect [14]. Most of
the LDL actions are mediated by apoprotein B (Apo B) that is
its major protein component. This protein mediates the inter­
action with the endothelial cells surface via different matrix
proteins such as proteoglycan, collagen, and fibronectin [14–
16]. Within the intimal microenvironment, LDL may be mod­
ified, mainly oxidized by lipoxygenase, myeloperoxidase, or
reactive oxygen species released in loco, thus damaging the
endothelium. The final result of this interaction is the activa­
tion of some transcription factors, such as NF-kappa B, leading
to a modulation of the gene expression profile and up-
regulation of adhesion molecules (CAMs), mainly VCAM1,
and selectins. Binding of these proteins with other membrane
proteins on circulating immune cells will facilitate their adhe­
sion and migration leading to plaque grow [17,18]. Recent
studies have indicated that within the subendothelial space,
LDL particles may aggregate by binding intimal proteoglycans.
These aggregates may infiltrate smooth muscle cells (SMCs)
via specific receptors belonging to the LDL receptor-related
protein superfamily in LDL receptor independent manner [19].
Thus, non-only macrophages but also SMCs finally contribute
to lesion formation [19,20]. Moreover, SMCs may also partici­
pate to the atherosclerotic plaque grow because by migrating
from the media into the intima they accumulate at the site of
lesion formation. Finally, these cells, beyond a continuous
proliferation lasting for years, are able to produce and release
extracellular matrix degrading enzyme that may induce ather­
osclerotic plaque rupture or erosion [21].
However, besides these mechanisms, plaque growth might
be due to cycles of repeated plaque ruptures and healing.
Indeed, plaque rupture does not always lead to an acute
fatal event since the majority of ruptures and/or erosions are
asymptomatic. In fact, autoptic studies in patients who died of
noncardiovascular causes and studies with imaging of coron­
ary tree have shown that plaque rupture was found in a small
Pathological
Causes substrate Diagnostic Tools
Atherosclerotic Invasive Coronary
Angiography
Atherosclerotic Invasive Coronary
Angiography
and Intracoronary Imaging
(IVUS or OCT)
Non- Invasive Coronary
atherosclerotic Angiography
and Functional Assessment
(FFR/IMR/CFR/
Acetylcholine Test)
Non- Invasive Coronary
atherosclerotic Angiography
and Functional Assessment
(FFR/IMR/CFR/
Acetylcholine Test)
 EXPERT REVIEW OF CARDIOVASCULAR THERAPY 353

number (less than 10%) of atherosclerotic lesions studied
[22,23]. In those lesions in which plaque rupture is not fol­
lowed by an occlusive thrombosis [22], the thrombus may
remain mural with incomplete lysis. The healing phase con­
tinues with thrombus reendothelialization followed by fibrous
thrombus organization: this phenomenon finally causes expo­
nential plaque growth [24].
2.2. The concept of vulnerability: a prone to rupture
lesion
Atherosclerotic plaque grow is associated with remodeling of
vessel wall: the lesions expand outward preserving the caliber
of the arterial lumen and then it begins to expand upon the
arterial lumen, finally causing the formation of lesions that
might progressively became “flow-limiting.” This is the case
of stable coronary plaques characterized by limited lipid accu­
mulation and thicker fibrous caps, usually responsible of
symptoms of effort angina pectoris [25].
Atherosclerotic plaque rupture is the most common trigger of
ACS (Figure 1, Panel A) [6,26]. Ruptured plaques often have large
lipid cores covered by a thin fibrous cap [15]. Disruption of the
atherosclerotic plaque causes exposure of thrombogenic sub­
stances, mainly tissue factor (TF) to the flowing blood [27]. TF
represents the natural initiator of extrinsic coagulation pathway,
and its exposure to other coagulation factors, mainly FVII and X,
contained in the blood stream, induces the activation of coagu­
lation cascade and, as final event, platelet aggregation via several
membrane receptors (Figure 1, Panel B), leading to the intracor­
onary thrombus formation (Figure 1, Panel A) [2,27].
The mechanisms involved into the translation from a stable
to an unstable atherosclerotic plaque remains to be clarified.
However, an increasing number of evidence, including several
reports by our group, have focused on the role of inflamma­
tion (local and systemic) as well as the on-site immune-
competent cells activation (both natural and adaptive
immunity) [3,28–30]. On this regard, it has been reported by
several functional and morphological studies that complicated
plaques are more inflamed and enriched of immune-
inflammatory cells than intact plaques [28,29] with increased
neovascularity and intraplaque hemorrhage [31,32].
Inflammation may exert different actions: the release of col­
lagen degrading enzymes, such as metalloproteinases, by
endothelial cells, SMCs, macrophages or even platelets, thus
inducing fibrous cap rupture, and the death of collagen-
synthesizing SMCs, thus contributing to loss of fibrous cap
integrity [28,32,33].
In the last two decades, the concept of vulnerability has
been proposed to describe plaques at high risk of imminent
rupture and thrombosis [34]. Specifically, it has been postu­
lated that plaque vulnerability might be considered as
a biomechanical phenomenon with a complex interplay
between different factors including applied plaque stresses,
structural features, and biological processes.
The prototypical vulnerable plaque is usually small, with
thin-cap fibroatheromas. Large necrotic core, high macro­
phage infiltration/activity in the cap, expansive remodeling
mitigating luminal obstruction (mild stenosis by angiography),
neovascularization, plaque hemorrhage, adventitial inflamma­
tion, and a spotty pattern of calcifications are common fea­
tures [24,31,32,35].
In the last years, several epidemiological studies have
clearly indicated the close relationship between cold tempera­
ture and acute coronary events [36–38]. Several hypothetical

Figure 1. Panel a: Atherosclerotic plaque formation is the final event of a complex network involved lipid deposition, endothelial dysfunction, white blood cells
recruitment, and activation. Intravascular thrombus formation occurs on a complicated atherosclerotic lesion with exposure of TF, coagulation cascade activation,
and platelet aggregation. Panel b: Platelets express different membrane receptors which bind several agonists able to induce a deep proteome modulation via
miRNAs activation and mRNAs alternatively splicing. Panel c: Within the atherosclerotic plaque, antigen-presenting cells may modulate the immune response by
interacting with naive T-cells, thus becoming effector T-cells. According to the stimuli, the interactions between various T-cell subsets may be generated (Th1, Th2,
Th17, Treg), thus defining the final fate of the lesion. Specifically, Th1 and Th17 seem to be associated with a progression/destabilization of atherosclerotic lesion.
Th2 and Treg are linked to regulatory/inhibitory effects.
354 G. CIMMINO ET AL.
mechanisms have been proposed to explain how cold tem­
perature might be involved in the pathophysiology of cardio­
vascular events. It has been suggested that catecholamines
plasma levels increase after stimulation of skin cold receptors.
This, in turn, causes vasoconstriction with increased blood
pressure together with increased heart rate finally leading to
plaque rupture and acute coronary events [39,40]. Moreover, it
has been suggested that acute events might be due to
enhanced thrombotic milieu for increased plasma concentra­
tions of clotting factors and platelets because cold tempera­
ture might significantly increase diuresis and, consequently,
blood viscosity [41].
Finally, a minor cause of ACS may be coronary embolism
[42]. Three types of coronary embolisms are known: 1) direct, 2)
paradoxical, and 3) iatrogenic. Direct coronary emboli com­
monly originate mainly from the left atrial appendage in
patients with atrial fibrillation who are not treated with antic­
oagulants [43]. Again, another cause of direct coronary embo­
lism might be a thrombus of the left ventricle specially in
patients with severe ventricular dysfunction or aneurysm
[44]. Finally, other sources might be the prosthetic aortic or
mitral valves [45]. The main cause of paradoxical coronary
embolisms is patent foramen ovale [46]. Finally, iatrogenic
coronary embolisms might be secondary to coronary interven­
tions [42].
3. Atherothrombosis: the role of
immuno-inflammation
3.1. Role of inflammation
In the last two decades, several epidemiological studies have
clearly shown that some systemic inflammatory markers, such
as C-reactive protein (CRP) Interleukin-1 beta and Interleukin-
6, might be useful prognostic markers to predict major car­
diovascular events in healthy subjects as well as in patients
with established cardiovascular disease [47–53]. CRP was the
first inflammatory marker that was correlated with cardiovas­
cular diseases. This protein was measured within the coron­
ary circulation of ACS patients and in patients with
cerebrovascular events [54–56]. However, more recent stu­
dies have clearly indicated that CRP might be no more con­
sidered as a simple marker but as an active partaker in ACS
pathophysiology. Indeed, several in vitro and in vivo studies
have shown that CRP exerts direct biological effects on
endothelial cells: it promotes expression of adhesion mole­
cules [57–60] and TF [61], stimulates release of MCP-1 [62]
and MMPs [63,64], secretion of other inflammatory cytokines
[65,66], increases iNOS and superoxide production, and
decreases eNOS, prostacyclin, and tPA expression [58,67].
CRP sustains an anti-inflammatory innate immune response
when circulating in a pentameric form, while as monomeric
form, it exerts potent proinflammatory and prothrombotic
actions. Interestingly, this conversion may occur at the site
of plaque rupture, mainly induced by activated platelets
[68,69].
The role of IL-1β and related intra- and extracellular signal­
ing in all stages of atherosclerosis has been also reported
[70,71]. This interleukin induces expression of CAMs and
chemokines, including MCP-1 [71], proliferation and differen­
tiation of SMCs, activation of monocytes, macrophages, and
secretion of different inflammatory mediators [70,72], and
generation of IL-6 and MMPs [72] that are closely related to
the fibrous cap rupture as indicated above. Noteworthy, the
CANTOS study has highlighted that anti-inflammatory therapy
with canakinumab, a monoclonal antibody against the IL-1β
pathway, could significantly reduce the rate of recurrent car­
diovascular events [53], thus reinforcing the hypothesis that
this inflammatory molecule plays an active role in pathophy­
siology of acute coronary events.
Lastly, other studies have underlined that IL-6 is also
involved in atherosclerosis. Specifically, it promotes the devel­
opment and destabilization of atherosclerotic plaques [52]. It
can be released by cardiomyocytes during myocardial ische­
mia-reperfusion, inducing CAMs expression with final damage
of the myocardium from the immune cells [73]. Moreover, IL-6
is elevated in animal model of cerebral ischemia and in the
cerebrospinal fluid of patients with acute stroke [73].
3.2. Role of immunity
The concept that an active immune response occurs in ather­
osclerosis as well as in ischemic myocardium is now well
accepted [74]. Enrichment of immune-competent cells within
atherosclerotic lesions has been reported by our group [75]
and others [76,77], and contribution to plaque vulnerability is
also proposed [28,78]. Beyond the role of monocytes/macro­
phages since the initial stage of plaque formation in ingest­
ing lipids and orchestrating immunological response by
releasing inflammatory mediators [79], other white blood
cells are involved in atherosclerosis, such as B and
T-lymphocytes [29,80]. Despite T-cells are a minority of the
leukocytes enriching the plaques, several reports suggest
their key regulatory role within atherosclerotic lesion [81]
by modulating the adaptive immune response and instruct­
ing the more abundant monocytes/macrophages of the
innate immune response [28,82]. Moreover, atherosclerotic
lesions are also infiltrated by several antigen-presenting
cells that in cooperation with soluble mediators released in
loco by activated macrophages may act simultaneously indu­
cing T-cells differentiation in different subsets [83]. Several
reports indicate that this polarization seems to define plaque
destiny, since some T-cells subtypes exert more proinflamma­
tory effects (i.e. Th1 and Th17 cells), while other subtypes
may act as negative regulators of inflammation (Treg and Th2
cells) [28,84]. T-cell activation and polarization are crucial for
plaque vulnerability [32,33,85]. It has been reported by our
group and others that in ACS patients, local and circulating
T-clonotypes recruitment is selective and not random [76,77]
with the release of specific cytokines (Figure 1, Panel C)
[47,83,86–88].
A study from our group has clearly documented a specific,
immune-driven response and inflammatory pathways within
the “culprit lesion” of patients presenting with ACS [75], show­
ing a specific oligoclonal T-cell expansion only in the vulner­
able plaque and not in the peripheral blood, indicating
a selective expansion driven by a given intraplaque antigen.

To date, the putative antigens responsible for this intrale­
sion activation are still under investigation [29]. Modified lipo­
proteins, such as oxidized LDL (oxLDL), are thought to be the
major determinant in T-cells activation via MCH-TCR interac­
tion [89–91] or even the specific receptor for oxLDL, namely
LOX-1 [92]. In line with this hypothesis, we have recently
reported that oxLDL may induce T-cell activation in TCR inde­
pendent manner inducing TF expression [93].
In the last decade, researchers have focused more attention
on a specific subset of Th-cells known as Th-17 that are able to
release large amounts of IL-17, IL-21 granulocyte–macrophage
colony-stimulating factor, and IL-6 upon activation [94]. In vivo
a small subset of CD161+ T-cell precursors may polarize into
Th-17 cells upon IL-1β plus IL-23 stimulation. Their involve­
ment in the pathogenesis of atherosclerosis is still matter of
debate because of controversial reports. Some studies indicate
that blocking IL-17 pathway may attenuate atherosclerosis
progression [95–97], while other reports correlate IL-17 signal­
ing with plaque destabilization and acute event [98,99]. On
this regard, we have reported high levels of trans-coronary IL-
17 and a higher number of Th-17 cells in a subgroup of ACS
patients presenting with a more severe disease with higher
troponin levels at admission, as compared to stable angina
patients. These data reinforce other studies on the possible
contribution of Th-17 cells in determining a more severe dis­
ease [98].
Moreover, we have shown that in vitro stimulation of
T-cells by a combination of IL-17 plus INF-γ may induce
expression of TF with procoagulant activity [100]. TF positive
T-cells have been also found in vivo in coronary circulation
as well as in thrombotic material aspirated from ACS
patients [100].
Finally, it has been postulated that the balance between
plaque complication, vascular obstruction, myocardial ische­
mia, and occurrence of clinical events is in charge of Treg
activity and its demodulation during acute myocardial infarc­
tion may worse the outcome [101]. Further studies are war­
ranted to better evaluate the role of Treg in CVD [102].
4. Platelets in atherothrombosis: not only
aggregation
The physiological role of platelets in primary hemostasis is well
known and studied [103]. Their main role is to prevent blood
loss when the vasculature is damaged [103]. The ‘classical’ point
of view about platelets in hemostasis has considered platelets
simply as the final effector of the coagulation cascade because
they lack of nuclei [103]. However, newer evidence accumulated
in the last two decades have pointed out other novel functions
beyond aggregation because they seem able to modulate the
immune response [104], to promote inflammation [105], and to
cause cancer metastasis [106]. Specifically, platelets have an
active role in innate immunity because they release several
inflammatory and bioactive molecules stored within granules
or synthesized upon activation [104]. These biochemical media­
tors, in turn, exert their effects by modulating the cells of the
innate immune system. Moreover, platelets are directly involved
as effector cells in innate immunity, have an active role in
EXPERT REVIEW OF CARDIOVASCULAR THERAPY 355
frontline host defense against microbial infection, and enhance
antigen presentation by APCs [104]. Moreover, platelets can
contribute to inflammation via direct secretion of proinflamma­
tory mediators such as TGF-β1, -β2, -β4, IL-1α, IL-1β, IL-2-4, −6-8,
−10, −11, TNF-α, TNF-β, IFNγ, involved in the regulation of
angiogenesis, cellular proliferation and differentiation, chemo­
taxis, vascular modeling, cellular interactions, and bone [105]. In
addition, upon activation through the expression of P-selectin,
platelets rapidly bind to monocytes, forming monocyte–platelet
aggregates (MPA) [107,108]. This interaction induces
a proinflammatory phenotype in circulating monocytes and
might be used in vivo as cellular biomarker of platelet activation
[109]. Of note, higher MPA levels have been reported both in
ACS patients and in those presenting with chronic coronary
syndromes (CCS) [110,111], as well as in patients with endothe­
lial dysfunction regardless of the presence of a coronary stenosis
[112]. Finally, different observations indicate a crosstalk between
platelets and cancer: cancer cells may promote direct platelet
aggregation or indirect platelet activation. These effect enhance
the release of extracellular matrix proteins and TF from endothe­
lial cells, thus favoring platelet adhesion and thrombus forma­
tion [106]. On the other side, platelets store and release several
angiogenic factors that balancing hemostasis and angiogenesis
within the tumor microenvironment finally contribute to cancer
angiogenesis, grow, and metastatic dissemination [106]. Taken
together, these observations give a newer point of view about
platelet role in atherothrombosis, since they should not be
considered only as the final effector of the coagulation cascade
but, on the contrary, as active players in the first steps of this
disease.
Recently, a growing body of evidence is highlighting the
importance of miRNAs in atherosclerosis development and pro­
gression specifically via the regulation of atherosclerosis-prone
genes [113]. miRNAs act by silencing their target genes, thus
affecting cells function and protein synthesis [113]. Several
reports indicate their role in endothelial [114] and
SMCs regulation [115–117] such as injury and consequent cell
attachment, growth, and inflammatory responses [118]. On this
regard, another interesting chapter about the involvement of
miRNA in atherosclerosis and atherothrombosis is related to the
role of platelet miRNA [119]. Despite platelets do not have
nuclei, they contain several mRNAs [120] and rough endoplas­
mic reticulum and polyribosomes, thus they have protein synth­
esis (Figure 1, Panel B) [121]. We have reported that upon
activation platelets are able to modify their proteome even in
absence of substantial change in transcriptome [122]. These
modifications are part of an intense alternative splicing of
mRNAs and miRNAs activity [123]. These small non-coding
RNA interacts with a target mRNAs as a negative regulator,
thus down-regulating protein expression [124]. The potential
role of Platelet-related miRNAs in the development of cardio­
vascular events is part of extensive research [125].
5. ACS and functional alterations of coronary flow:
beyond atherothrombosis
In about 10% of patients with ACS, myocardial ischemia is not
due to atherothrombosis. In these cases, a functional altera­
tion of coronary circulation involving both large epicardial
356 G. CIMMINO ET AL.
coronary arteries or the coronary microcirculation have been
indicated as responsible of the acute event [6]. The main role
of the coronary circulation is to provide the cardiac muscle
with the oxygen it requires by regulating the coronary blood
flow. In fact, myocardial oxygen extraction is almost maximal
at rest, thereby an increase in oxygen demand would result in
a corresponding increase in coronary blood flow. Coronary
microvascular disease (CMD) refers to the dysfunction of this
mechanism leading to myocardial ischemia and it is character­
ized by the presence of some abnormalities in the ‘function’
and ‘structure’ of the coronary microcirculation due to
endothelial and SMCs dysfunction. Most of the patients with
CMD do not present ‘significant’ atherosclerotic obstructive
coronary disease at coronary angiography despite presenting
with typical chest pain.
At the end of 1999 the WISE study was published reporting
an abnormal coronary flow reserve (CFR) in half of women
with suspected ischemic heart disease but with non-
obstructive coronary arteries [126]. Similarly, other studies
showed that approximately 50% of patients presenting with
myocardial infarction with non-obstructive coronary arteries
(MINOCA) experience CMD mainly associated with microvas­
cular spasm [127–131].
A previous meta-analysis of 28 studies showed that
MINOCA is relatively common accounting for 6% of all myo­
cardial infarctions (MI) [128] .Females are more common than
men and patients are slightly younger as compared with MI
associated with CAD [128,132]. MINOCA patients were initially
considered to have a benign prognosis, however, recent stu­
dies and metanalysis have shown an increased risk of both
new cardiovascular events and hospitalization for heart failure
and stroke with a mortality rate of 2% per annum [132–134].
In the pathogenesis of CMD are involved both endothelium-
dependent and non-endothelium-dependent mechanisms.
Endothelium-dependent mechanisms refer to the endothelial
dysfunction, which is responsible of a dysregulation of the micro­
vascular reactivity, affecting the physiological flow-mediated
vasodilation that is needed when an increased myocardial oxy­
gen demand occur [135]. This final event may even result in
a paradoxical vasoconstriction, thus producing microvascular
Figure 2. Pathophysiology of Myocardial infarction in non-obstructive CAD. The most common causes of MINOCA are represented by coronary plaque disease,
coronary dissection, coronary artery spasm, coronary microvascular dysfunction, and coronary thromboembolism.
spasm. On the contrary, non-endothelium-dependent mechan­
isms refer to structural remodeling of coronary microvasculature.
It consists in intimal thickening, perivascular fibrosis, capillary
rarefaction with increased microvascular resistances finally
resulting in a CFR reduction [136]. Two different mechanisms
have been postulated to explain pathophysiology of MINOCA:
a. an acute trigger on top of a prolonged ischemia due to
a chronic microvascular dysfunction or, b. a sudden increase of
resistance as consequence of an acute increase of adrenergic
tone, as reported in Figure 2 [137]. Based on the pathogenesis
and in light of a tailored therapeutic approach, an invasive
assessment may plays a crucial role [137,138]. The first step is
ruling out hidden atherosclerotic causes such as acute plaque
rupture/erosion or the presence of functionally significant and
angiographically underestimated intermediate coronary artery
stenosis, as shown in Table 1. IVUS and OCT are useful to assess
the quality of atherosclerotic plaques among the epicardial cor­
onary circulation, identifying signs of plaque disruption or cor­
onary dissection, while FFR allows functional assessment of
angiographically intermediate coronary stenosis ruling out the
presence of hemodynamically significant obstructive CAD. Once
ruling out atherosclerotic causes of MINOCA, both thermodilu­
tion-based assessment of coronary microvascular function and
provocative test with acetylcholine can be performed. The for­
mer evaluates microvascular vasodilatation by measuring both
CFR and index of microvascular resistance (IMR), the latter is
useful to rule out endothelial dysfunction presenting with para­
doxical vasoconstriction, induced by intracoronary acetylcholine
injection. In fact, in case of intact endothelium, endothelium-
dependent vasodilation normally opposes to α-adrenergic vaso­
constriction, while at the early stage of the atherosclerotic
process a constrictor response emerges [139]. Of note, in subjects
with normal coronary angiograms, there is no α-adrenergic cor­
onary constrictor tone at rest and the constrictor response during
sympathetic activation is mediated by α2-adrenoceptors and
mainly affects the microcirculation. In patients with endothelial
dysfunction, sympathetic activation leads to an enhanced α-
adrenergic vasoconstriction possibly leading to myocardial
ischemia in atherosclerotic patients, in whom the α2-adrenergic
coronary constriction tone is enhanced [139].

Another alternative cause of CMD may be coronary micro­
embolization [140]. Microemboli usually consist of material
coming from the atherosclerotic plaque, including cholesterol,
platelet and platelets-leukocyte aggregates, and fibrin [141–
145]. Microembolization induces patchy microinfarcts asso­
ciated with a typical time-course of the regional contractile
function which is characterized by an immediate decrease
followed by a partial recovery and a subsequent deterioration
[146,147]. Several studies have indicated that inflammation
might play a pivotal role in this phenomenon. Specifically,
experimental studies have shown a significant unbalance of
expression of cytokines with pro and anti-inflammatory role in
coronary microembolization (9). Among them, TNF-alpha
appears as the pivotal molecule because it is up expressed,
in both macrophages and cardiomyocytes, and it is linked to
a negative inotropic effect [148–150]. Coronary microemboli­
zation may occur either spontaneously or because of percuta­
neous coronary interventions (PCI). In the context of a stable
clinical setting, coronary microembolization can be easily iden­
tified after PCI where a transient increase of high-sensitive
troponins identifies the occurrence of a peri-procedural myo­
cardial injury [151]. However, the elevation in troponin levels
after PCI can be associated with either a side-branch occlu­
sion/damage or distal coronary microembolization. On the
contrary, during ACS, it can be difficult to distinguish whether
the increase in cardiac biomarker levels is mainly due to
spontaneous coronary microembolization rather than other
causes. In this setting, microcirculation might also be exposed
to myocardial ischemia/reperfusion injury. The no-reflow phe­
nomenon is the practical example of this damage as it may
occur after primary PCI, particularly after thrombolysis (rescue
PCI), when soon after revascularization of the occluded cor­
onary artery there is slow- or even no-flow downstream the
vessel [152,153]. Obstructed microcirculation can be damaged
by reversible edema eventually associated with capillary
destruction and intramyocardial hemorrhage [152,154–156].
Microcirculation protection, including different strategies
ranges from pre- or postconditioning, remote ischemia and
hypothermia, represents the new frontiers of the modern
cardiology.
According to the Coronary Vasomotion Disorders International
Study Group (COVADIS) indications, during acetylcholine test, the
presence of both typical symptoms (usually experienced by the
patients) and ischemic ECG changes, in the absence of significative
epicardial spasm, allow the diagnosis of CMD associated with
microvascular vasospasm [131]. However, CMD cannot be consid­
ered only an isolated disease, since it might be discovered also in
patients presenting with CCS. In addition, CMD can also be
a consequence of myocardial injury either associated with coron­
ary revascularization or others ischemic or nonischemic causes
[157–161]. It has been found to be strongly associated with
heart failure with preserved ejection fraction, diabetes, hyperten­
sion, and it also confers an increased risk of adverse cardiovascular
events [162].
In conclusions, ACS are complex clinical syndromes with
the involvement of different pathophysiological mechanisms,
including vasomotion abnormalities and coronary microvascu­
lar dysfunction. The latter represent the main mechanisms
associated with the occurrence of MINOCA.
EXPERT REVIEW OF CARDIOVASCULAR THERAPY 357
6. Conclusions
The current guidelines simplify the ACS based on ECG mod­
ifications: ST-segment myocardial infarction versus non-ST-
segment myocardial infarction. However, in the last few
years, this simplified clinical view has been associated in par­
allel to a complex pathophysiological scenario since not all
cases of ACS fit the coronary stenosis substrate. As we have
discussed in the present manuscript, we need to move
beyond atherosclerotic plaque-related stenosis considering
arterial spasm, microvascular dysfunction, rupture without
inflammation, and immunity involvement as instigators of
plaque erosion.
Control of traditional risk factors remains essential in pre­
venting ACS occurrence, but the role of inflammation, immu­
nity, vasospasm, and microvascular dysfunction should also be
considered especially for the less well-recognized pathways to
acute myocardial ischemia discussed in the present review.
Newer biomarkers (such as miRNAs) or application of novel
imaging techniques may represent the challenge in the triage
of ACS patients. Based on the ACS mortality and morbidity
rate, we cannot to be satisfied with our current approach to
ACS patients. We are maybe in need of a more personalized
precision deployment of treatment strategies with a look to
the diverse underlying causes of acute myocardial ischemia.
7. Expert opinion
In the last few years, despite the great advancements in our
understanding of ACS pathophysiology, ischemic cardiovascular
diseases and their complications remain the major cause of mor­
bidity and mortality in western countries. Atherothrombosis
accounts almost the majority of ACS, while a small contribution
comes from the non-obstructive coronary artery forms. Although
it has been clearly indicated that several mediators of inflamma­
tion and many cell types belonging to the immunological system
are actively involved in the development of stable atherosclerotic
plaques and their instability, the relative role of single cell type and
their reciprocal role in the network of immunity are not completely
understood yet. Moreover, the identification of possible antigens
responsible of activation of cells of immunity is a still unexplored
area with many questions without answers. This is a crucial area of
interest because identification of these antigens might be consid­
ered as the first step to study newer potential therapeutical tar­
gets. The hypothesis of a “vaccine” against ACS might be
a fascinating drive to stimulate the research in this field. Thus,
a look into the future of therapy of ACS might consider not only
drugs against lipids and thrombosis but also drugs to obtain fine
modulation of immune-inflammation in order to avoid not only
plaques grow but also their conversion from ‘stable’ to ‘unstable.’
This complex pathophysiological scenario is not applicable
in the ACS in which a non-obstructive CAD (MINOCA) is docu­
mented during the acute event. Since this is another largely
unexplored area, the currently available tools in the cath-lab
with the assessment of both CFR and IMR together with
provocative tests will provide an improvement of our knowl­
edge of the pathophysiology of this condition in order to
provide the patients with the best tailored therapy.
358 G. CIMMINO ET AL.
Prevention of new onset or recurrent coronary events is the
challenge of the next future. The great improvement on the
application of novel imaging and molecular techniques might
represent the opportunity to early identify the patient at risk to
develop an ACS and better characterize the specific pattern
involved in the acute as well as the chronic phase. Based on the
current knowledge, immune-inflammatory modulation using spe­
cific drugs might be of interest. Identification of the possible
antigens involved in the immune system activation within athero­
sclerotic lesion might shed more light to pursue new and specific
therapeutical targets. On the other hand, the management of
non-obstructive CAD remains to be better defined. Finally, the
discovery of novel roles for the platelets beyond the simplified
aggregation process represent another important finding to
further investigate.
Declaration of Interest
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other
relationships to disclose.
Author contributions
All authors equally contributed to this paper with conception and design
of the study, literature review and analysis, drafting and critical revision
and editing, and final approval of the final version.
Funding
This paper funded by V:ALERE 2019 grant from University of Campania
Luigi Vanvitelli.
ORCID
Plinio Cirillo http://orcid.org/0000-0001-7818-4952
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